No.	Explanation
RM01	Comprehensive quality and/or risk management documentation (QM/RM documentation) is available Qualitätshandbuch (24.02.2022)
RM02	Regular further education and training measures
RM03	Employee surveys
RM04	Clinical emergency management Qualitätshandbuch (13.09.2023)
RM05	Pain management Qualitätshandbuch (03.05.2022)
RM06	Fall prophylaxis Qualitätshandbuch (24.02.2022)
RM07	Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”) Qualitätshandbuch (22.05.2023)
RM08	Regulated handling of custodial measures Qualitätshandbuch (15.06.2020)
RM09	Regulated handling of occurring malfunctions of devices Qualitätshandbuch (14.12.2021)
RM10	Structured implementation of interdisciplinary case discussions/conferences Case review conference Qualitätszirkel Tumorkonferenzen Mortalitäts- und Morbiditätskonferenzen Palliativbesprechungen Teamkonferenzen Fallbesprechungen Schmerztherapie
RM12	Use of standardised information sheets
RM13	Application of standardised surgical check lists
RM15	Preoperative, complete presentation of necessary findings Prozessbeschreibung Administrative Aufnahme (in Zusammenarbeit mit der KKL) (30.03.2021)
RM16	Procedure to avoid procedural and patient mix-ups Qualitätshandbuch (10.11.2021)
RM17	Standards for recovery and postoperative care Postoperative Anästhesiologische Anordnungen & Dokumentation für die Station (in Zusammenarbeit mit der KKL) (04.04.2024)
RM18	Discharge management Qualitätshandbuch (24.06.2020)

Fault reporting systems

Internal to the institution

Conference committee

Conference frequency: monatlich

Measures

Einsatz von Stationsapotheker zur Erhöhung der Arzneimitteltherapiesicherheit

No.	Explanation
IF01	Documentation and procedural instructions for handling the error reporting system are available As of: 18.12.2023
IF02	Internal evaluation of the received reports taken monatlich
IF03	Training of employees in handling the error reporting system and in implementing the findings from the error reporting system taken monatlich

No.

Explanation

IF01

Documentation and procedural instructions for handling the error reporting system are available

As of: 18.12.2023

IF02

Internal evaluation of the received reports

taken monatlich

IF03

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken monatlich

Across all institutions

Conference committee

Conference frequency: halbjährlich

No.	Explanation
	Other
EF06	CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association)

No.

Explanation

Other

EF06

CIRS NRW (North Rhine and Westphalia-Lippe Medical Associations, North Rhine-Westphalia Hospital Association, North Rhine and Westphalia-Lippe Associations of Statutory Health Insurance Physicians, German Medical Association)